Volume 41 | Issue 40
Download this FYI as a printable PDF
The Department of Health & Human Services has finalized the 2019 out-of-pocket maximums at $7,900 for self-only coverage and $15,800 for other than self-only coverage.
Background
Each year, the Department of Health & Human Services (HHS) releases the HHS Notice of Benefit and Payment Parameters that provides important guidance related to the Affordable Care Act (ACA) marketplaces and various ACA provisions. Last fall, HHS released the proposed rule for 2019. (See our November 21, 2017 For Your Information.) On April 9, HHS released the final rule and a fact sheet summarizing the guidance. While primarily focused on the ACA marketplaces and insurers offering products in the marketplaces, the rule finalizes the 2019 ACA out-of-pocket maximums that affect large employer and self-insured group health plans.
Caution for High-Deductible Health Plans
High-deductible health plans intended to be HSA-compatible are subject to lower OOP maximums — the 2019 limits are $6,750 for self-only coverage and $13,500 for other than self-only coverage. (See our May 14, 2018 FYI.)
Out-of-Pocket Maximums
Effective for plan years beginning on or after January 1, 2014, the ACA imposes annual out-of-pocket (OOP) maximums on the amount that an enrollee in a non-grandfathered health plan, including self-insured and large group health plans, must pay for essential health benefits (EHB) through cost-sharing. (See our March 11, 2014 For Your Information.)
For plan years beginning in 2019, the OOP limits will be $7,900 for self-only coverage and $15,800 for other than self-only coverage. This represents an increase of $550 for self-only coverage and $1,100 for other than self-only coverage over the 2018 OOP maximums of $7,350 and $14,700 respectively.
ACA Indexed Dollar Amounts
The table below summarizes the ACA indexed dollar limits for 2019 and prior years.
| ACA Indexed Dollar Amounts | ||||||||
| Out-of-Pocket Maximums (1,5) | PCORI Fee (2,5) |
Transitional Reinsurance Fee (6) | Health FSA Salary Reduction Cap (3,5) | Employer Shared Responsibility Annual Assessments (1,4,6,7,8) | ||||
| Self-Only | Other Than Self-Only |
4980H(a) – Failure to Offer Coverage | 4980H(b) – Failure to Offer Affordable, Minimum Value Coverage | Affordability Threshold Under 4980H(b) | ||||
| 2019 | $7,900 | $15,800 | N/A | N/A | Not Available | $2,500 (Est.) | $3,750 (Est.) | Not Available |
| 2018 | $7,350 | $14,700 | Not Available | N/A | $2,650 | $2,320 | $3,480 | 9.56% |
| 2017 | $7,150 | $14,300 | $2.39 | N/A | $2,600 | $2,260 | $3,390 | 9.69% |
| 2016 | $6,850 | $13,700 | $2.26 | $27 | $2,550 | $2,160 | $3,240 | 9.66% |
| 2015 | $6,600 | $13,200 | $2.17 | $44 | $2,550 | $2,080 | $3,120 | 9.56% |
| 2014 | $6,350 | $12,700 | $2.08 | $63 | $2,500 | $2,000 | $3,000 | 9.50% |
| 2013 | N/A | N/A | $2.00 | N/A | $2,500 | N/A | N/A | N/A |
| 2012 | N/A | N/A | $1.00 | N/A | N/A | N/A | N/A | N/A |
Notes:
1 Indexed to increase in average per capita premium for U.S. health insurance coverage in prior calendar year. Out-of-pocket maximum does not apply to grandfathered plans or retiree-only plans
2 Indexed to increases in national health expenditures
3 Indexed for CPI-U
4 One-twelfth of annual amount assessed on monthly basis. No assessments for 2014
5 Applicable dollar amount affected by when plan year ends. No assessment for plan years ending on and after October 1, 2019
6 Applies on a calendar year basis
7 2019 assessment amounts have not been released. Estimate based on increase in average per capita premium for U.S. health insurance coverage as determined by HHS
8 Affordability threshold adjusted consistent with Code Section 36B(b)(3)(A)(i)
N/A – Not applicable